Namcs 10-12 OMB Att H

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National Ambulatory Medical Care Survey

NAMCS 10-12 OMB ATT H

OMB: 0920-0234

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ATTACHMENT H
2010 NAMCS Instruction Booklet

SECTION I IDENTIFICATION AND GENERAL INSTRUCTIONS/INFORMATION
A.

Name

Sampling

LISTING PATIENT VISITS - Keep daily lists of all patient visits beginning at
midnight on the first date of the reporting period (provided on the cover of this
booklet) and continuing through the last date of the reporting period (also
provided on the cover). For additional information on how and who to list,
refer to page 5 - "Listing Patient Visits" and page 6 - "Eligible Visits."

SELECTION OF PATIENT VISITS - Select a sample of patient visits
following the instructions on the cover of this booklet. (See page 6 - "Sampling
Procedures – Selecting Patients for Sample" for additional information on
sampling patient visits.)

Patient Record Form Numbers
1.

Folio Number:

Additional Folio Number:

Contact the field representative when additional pads of Patient Record forms
are needed. Check the Patient Record forms to make sure that they are either
light blue (form type A) or red (form type B).

Instructions - General instructions for completing Patient Record forms are on
page 7. Instructions for the individual items begin on page 10. Job Aids for
completing the Patient Record forms include the NAMCS-80 and
NAMCS-150.

Field Representative Information

Other Contact

Name

_______________________________

Phone Number

_______________________________

SECTION II

INTRODUCTION

Purpose and Background
Ambulatory medical care is the largest and most widely used segment of the American
health care system. Fewer than one person in ten is hospitalized in the United States each
year, but nearly three out of four persons visit a physician in the same period. The
physician's office is clearly the focal point of medical care in the United States. The U.S.
Census Bureau conducts the National Ambulatory Medical Care Survey (NAMCS) for the
Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics
(NCHS), in order to obtain data on this important part of our country's health care system.
Until the advent of the NAMCS, very little was known about the distribution, purpose,
and outcome of visits to physicians' offices. For example, there were no reliable data on
the following:
●

The nature of the health problems which people bring to physicians in
their offices

●

How these problems break down by the patient's age, sex, or race

●

How physicians treat these problems

●

How health problems vary by such factors as type of physician, season of
year, or kind of community

Yet this information is essential for medical education and for the planning and
administration of health services. There is a great need to make medical education more
efficient and more relevant. This requires good data on what actually happens in the
physician's office.
Similarly, the planning, employment, and administration of health care facilities and
services cannot be rationally accomplished when information is lacking about the
all-important segment of medical care which is dispensed in physicians' offices.
Variations in the nature and volume of this type of care, according to medical specialty,
size of community, geographical region, physician characteristics, as well as
characteristics of patients, have important implications for better planning and utilization
of medical personnel and facilities.
The endorsement of this survey by many professional medical societies indicates the
interest and importance which the medical profession itself attaches to it. For the 2010
survey, 20 professional associations have provided letters supporting physician
participation in the NAMCS.
Scope
The NAMCS is a continuous survey, with a different sample of physicians participating
each week throughout the year. Conducted every year from 1973 through 1981, and again
in 1985, the original sample size of 1,600 physicians was expanded to 3,000 from 1975
3

through 1981, and expanded further to 5,000 in 1985. Beginning again in 1989, it has run
continuously with a yearly sample of approximately 3,000 physicians. Results of the
NAMCS have been extensively published and disseminated over the years.
Compared to 2009, the 2010 NAMCS sample is slightly expanded with a total of 3,400
physicians. The National Center for Chronic Disease Prevention and Health Promotion
(NCCDPHP) is once again sponsoring the inclusion of an additional 200 primary care
physicians (general/family practice, internal medicine, obstetrics/gynecology and
pediatricians). In addition, 200 oncologists were added to the survey to build upon efforts
by the National Caner Institute (NCI) to improve estimates of physician services that are
needed by clinical and public policymakers to assess and monitor the quality of cancer
care. As in previous years, we will have a supplementary sample of 104 Community
Health Centers (CHC). Survey eligibility in the CHCs include physicians, nurse
midwives, nurse practitioners, and physician assistants. We will sample three
physicians/mid-level providers per CHC.
The primary objective of the NAMCS is to collect data on a representative national sample
of patient visits to office-based physicians who are concerned with direct patient care.
The NAMCS definition deliberately excludes certain types of medical practices. For
example, the following providers/physicians are outside the scope of the survey:
●

Physicians in military service

●

Certain specialists, such as those in radiology, pathology and
anesthesiology

●

Hospital-based physicians working with inpatients, emergency
departments, or outpatient departments

●

Teachers or researchers who do not practice in private offices

●

Federally-employed physicians such as those in the Department of
Veterans Affairs (VA)

●

Physicians who exclusively see patients in industrial or institutional
settings

Study Roles
The National Center for Health Statistics has contracted with the Census Bureau to
implement the data collection activities for the National Ambulatory Medical Care Survey.
Trained Census Bureau field representatives will perform the following activities:
●

Contact selected physicians/CHC providers to screen them for eligibility
and arrange an appointment with them or other designated representative
to further discuss the study

●

Assist the office staff as requested in obtaining the necessary approval for
participation in the study
4

●

Obtain basic practice information on the physicians/CHC providers and
select the ambulatory care practice(s) to be included in the data collection

●

Show office staff how to select a sample of patient visits and record the
data

●

Monitor the data collection procedures during the reporting period.

We are asking the office staff to do the following two activities:
●

Select a sample of patient visits during a specific 1-week reporting period
following the specific sampling guidelines provided

●

Complete a one-page form for each selected visit

A Census Bureau field representative will visit the office to resolve any problems with
sampling patient visits or completing Patient Record forms, and to collect any forms
already completed. If any problems arise, or assistance is otherwise needed, contact the
field representative or other contact (as listed in items D and E on page 1) immediately.
Data Uses
The list of data users is quite extensive and includes medical associations, universities and
medical schools, and government agencies. Please see the one-page brochure titled
“Illustrative Uses of Survey Data” in the public relations package for a detailed list of data
use examples.
Authorization and Assurance of Confidentiality
The National Center for Health Statistics has authority to collect data concerning the
public's use of physicians' services under Section 306 (b) (1) (F) of the Public Health
Service Act (42 USC 242k). Any identifiable information will be held confidential and
will only be used by NCHS staff, contractors, or agents, only when necessary and with
strict controls, and will not be disclosed to anyone else without the consent of you. By
law, every employee as well as every agent has taken an oath and is subject to a jail term
of up to five years, a fine up to $250,000, or both if he or she willfully discloses ANY
identifiable information about your patients. Furthermore, the names or any other
identifying information for individual patients are never collected. Assurance of
confidentiality is provided to all respondents according to Section 308 (d) of the Public
Health Service Act (Title 42 U.S. Code, 242m(d)) and the Confidential Information
Protection and Statistical Efficiency Act (Title 5 of PL 107-347).
HIPAA
The requirements of the Health Insurance Portability and Accountability Act (HIPAA)
Privacy Rule on health information permits you to make disclosures of protected health
information without patient authorization for (1) public health purposes, or (2) research
5

that has been approved by an Institutional Review Board, or (3) under a data use
agreement with NCHS. There are several things that you must do to assure compliance
with the Privacy Rule including providing a privacy notice to your patients that indicates
that patient information may be disclosed for either research or public health purposes, and
a record that a disclosure of information to CDC for the NAMCS was made. More
specific information can be obtained about Privacy Rule disclosure requirements on our
web site mentioned below.
NAMCS Participant Web Page
The National Center for Health Statistics has a web page devoted to the common
questions and concerns of physicians/CHC providers participating in the National
Ambulatory Medical Care Survey. The participant Web site can be accessed at
www.cdc.gov/namcs. Refer to EXHIBIT B on page E-4 for the table of contents.
SECTION III SAMPLING
Overview
The physicians, CHC providers, and visits chosen for the study are selected by wellestablished statistical methods. The sample design is comprised of multiple stages to
ensure that the sample of physicians, CHC providers, and visits selected are representative
of those throughout the United States. The participation of each physician and CHC
provider is crucial, since each physician and CHC provider in the sample represents many
others in the country. In each selected office a sample of patient visits is chosen.
Keeping respondent burden and survey costs as low as possible are always important
considerations when designing a study. Sampling allows us to make national estimates of
the volume and characteristics of patient visits from a small sample of visits, physicians,
and CHCs, while reducing both the cost of the study and the work asked of the
physician/CHC staff. However, sampling procedures must be implemented accurately or
large errors will result, adversely affecting the data. The National Center for Health
Statistics selects the physicians and CHCs to be used for the study. However, the
responsibility for sampling patient visits lies with the office staff. Procedures for
selecting patient visits have been designed to be simple and easy to implement. Census
Bureau field representatives will instruct the office staff on these procedures.
Patient visits are systematically selected over the 1-week reporting period. The sampling
procedures are designed so that on average, approximately 30 visits are selected from the
physician’s practice. The same procedure applies to the CHC in that approximately 30
visits will be selected from the workload of the sampled physicians or mid-level providers.
Listing Patient Visits
A daily listing of all patient visits must be kept or constructed by each participating office
so that a sample of visits can be selected using the prescribed methods. The list of patient
visits may be taken from an arrival log or other source of recording patient visits like the
“Patient Visit Worksheet” found in the back of this booklet on page E-7. The order in
which the patients are listed is not important. However, it is crucial to have a complete
6

listing of all patients receiving treatment during all hours of operation. The list should
include those patients who came without previously being scheduled and those with
appointments, but it should exclude persons who canceled appointments or were "no
shows."
Once visit sampling begins, the order of the names must not change. Sampling procedures
require that each visit be selected at a predetermined interval (for example, every 2nd
patient, every 10th patient, every 15th patient, etc.). This is the "Take Every" pattern. If a
patient is inserted into the list after sampling has already been done, the pattern will be off
and the visits must be resampled. Please refer to the example in Exhibit C, page E-5.
Eligible Visits
A "visit" is defined as a direct, personal exchange between an ambulatory patient and a
physician, CHC provider, or a staff member acting under the direct supervision of a
physician, for the purpose of seeking care and rendering health services. Visits solely for
administrative purposes and visits in which no medical care is provided are not eligible.
The following are types of visits/contacts which should be excluded:
●

Persons who visit only to leave a specimen, pick up a prescription or
medication, or other visit where medical care is not provided

●

Persons who visit to pay a bill, complete insurance forms, or for some
other administrative reason

●

Telephone calls or e-mail messages from patients

It may be helpful to provide a brief reason for the patient's visit on the patient visit list/log
to indicate if the visit should be excluded from the sample. If a sample list is made before
the sample day begins, and it is determined that a patient will miss an appointment,
remove them from the list of potential sample patients, and continue to sample with the
next applicable patient. However, if you discover after the fact that a patient didn’t show
up, was sampled, and minimal information has been completed on a Patient Record form,
write “VOID” in the white space of the top margin of the Patient Record form to the right
of the “Incorrect” box. Do NOT writ “VOID” ACROSS the Patient Record form for any
reason.
Similarly, if a patient leaves before seeing the physician/provider and the sample list was
created beforehand, simply delete them and sample the next appropriate patient. More
likely, these patients will have been sampled and determined later to have left before being
seen. For these visits, also mark “VOID” in the white space of the top margin of the
Patient Record form to the right of the “Incorrect” box.
If you discover that another type of ineligible visit was accidentally included in the sample
list (e.g., a patient in a group practice obtaining care from someone other than the sampled
physician) once again mark "VOID" in the white space of the top margin of the Patient
Record form to the right of the “Incorrect” box.
Sampling Procedures-Selecting Patients for Sample
7

The 1-week reporting period for this office is recorded on the cover of this booklet. It
includes the date for beginning data collection, as well as the date for completing data
collection. To determine which patient visit to sample first, refer to the instructions at the
bottom of this booklet's cover. The first part of the instruction directs staff to begin with
the patient listed on a specific line number of the log on the first day of data collection.
Locate this patient visit on the list and mark the name to indicate that it is the first patient
visit sampled.
To continue sampling, refer once again to the instructions on the cover. Select every nth
patient. Continue counting down the patient list until you arrive at the nth patient name
listed. This is the second patient selected for the sample. This process is repeated to
select subsequent patient visits for the sample.
For example, if the sampling instructions indicate that you begin with the 3rd patient listed,
and select every 15th patient, you would select the 3rd, 18th, 33rd and so forth. See
EXHIBIT C on page E-5 for an optional worksheet marked with an example of a sampling
pattern. Be sure to follow the sampling pattern given on the cover of this booklet.
After each selection, mark or circle the patient name to indicate its inclusion in the sample,
and to indicate where to begin for sampling the next patient visit. This pattern of selecting
every nth patient is called the Take Every pattern. The pattern remains consistent
throughout the remainder of the reporting period and should be followed continuously
(from shift to shift, and day to day). Do not start fresh with a new "Start With" after the
end of a shift or day.
Group Practice and CHC Sampling
A situation requiring special attention is the group practice or CHC where the patients for
ALL the physicians and mid-level health care providers enter their names on the same
sign-in sheet. The only patients eligible for sampling are those visiting the physician or
CHC provider selected for the NAMCS. There are two options for handling this situation.
One, make a special effort to ignore and skip over the lines on the sign-in sheet occupied
by patients visiting other physicians or CHC providers. Two, use the worksheet found in
EXHIBIT D, page E-7 to maintain a separate list of patients visiting the NAMCS
physician or CHC provider. For example, transcribe the patient’s name from the
practice’s general sign-in sheet to the special NAMCS worksheet. Select the sample from
the worksheet. Whatever approach you apply, make sure that only patients visiting the
sampled physician/CHC provider are included in the sample selection.
SECTION IV COMPLETING PATIENT RECORD FORMS
Organizing Visit Sampling and Data Collection
A Patient Record form is completed for every patient visit selected in the sample during
the 1-week reporting period. There are two types of Patient Record forms: (1) form A is
one-sided and consists of 13 items, and (2) form B is identical to A, but is two-sided and
has 14 items with one additional question about cholesterol lab values on the back. Which
form you were given instructed to complete was based on your primary specialty. In either
8

case, both require only short answers and take approximately 6 minutes to complete the A
folio, and about 9 minutes to complete the B folio. These forms will require even less
time to complete as staff become more familiar with the items.
The Patient Record forms may be completed either during the patient's visit, immediately
after the patient's visit, at the end of the shift, day, etc., or in some combination of these,
whichever is most convenient for the staff. In some cases, a nurse or clerk may furnish the
information for certain items prior to the patient's visit, leaving the remainder of the items
to be completed by the attending health care provider during or immediately after the visit.
In other situations, it may be more convenient to complete all records at the end of the
shift or day by one designated person. Whatever method you choose, it is strongly
suggested that the forms be completed at least on a daily basis. Retrieving the records at a
later date may prove to be difficult and time-consuming. Also, patient information will be
fresher in the minds of the staff in case clarification is needed.
Staff members completing Patient Record forms must be familiar with medical terms and
procedures since most items on the form are clinical in nature. They must also know
where to locate the information necessary for completing the forms. To ensure that
complete coverage is provided for all shifts and days, the responsibility for data collection
may require the participation of several staff. We ask that each participating office/CHC
appoint a Data Coordinator to coordinate the personnel involved in the study and their
activities. The Data Coordinator's responsibilities will include supervising and/or
conducting the selection of the sample visits and the completion of the Patient Record
forms.
Prior to the office’s/CHC’s assigned reporting period, the Census Bureau field
representative will meet with the physician/CHC provider and discuss the organization of
sampling and the process of completing the Patient Record forms. The physician/CHC
provider then determines which staff will be needed in the data collection activities. The
Census Bureau field representative will train the staff on sampling and data collection.
Completing the Patient Record Form
The Patient Record form consists of two sections separated by a perforated line (See
EXHIBIT A on page E-1 for an example of both the A and B Patient Record forms). The
top section of the form contains two items of identifying information about the patient the patient's name and the patient’s medical record number. It is helpful to enter the
information for these items immediately following the selection of the patient visit into the
sample. The top section of the form remains attached to the bottom until the entire form is
completed. To ensure patient confidentiality, staff should detach and keep the top section
before the Patient Record forms are collected by the Census Bureau field representative.
The Data Coordinator should keep this portion of the form for a period of four weeks
following the reporting period. Should the Census Bureau field representative discover
missing or unclear information while editing the forms, he or she may recontact the Data
Coordinator to retrieve this information. The top section can be matched to the bottom by
the seven digit identification number printed on both sections of the form. The field
representative will provide this identification number when requesting information.

As mentioned earlier, the he bottom section of the form consists of 13 or 14 brief items
designed to collect data on the patient's demographic characteristics, reason for visit,
diagnosis, etc. Item-by-item instructions begin on page 10 of this booklet. To ensure
patient confidentiality, please do not record any patient identifying information on the
bottom portion of the form.
Each office/CHC provider receives a folio containing a pad of Patient Record forms
specifically assigned to that office/CHC provider. The type of folio you receive, A or B,
depends on your primary specialty. You should NOT receive both types of forms. If
you receive both types of forms, please contact the field representative or other
contact (as listed in items D and E on page 1) immediately. An ample supply of forms
is included in the event that some are damaged or destroyed, or the physician/CHC
provider sees a much higher volume of patient visits than initially expected. Should the
supply of forms for this office run low, please contact the Census Bureau field
representative or other contact provided in items D and E on page 1 of this booklet. If
possible, try not to interchange assigned office folios (i.e., folio for office #1 should
only contain visits from office #1). Check the Patient Record forms to make sure
that they are either light blue (A forms) or red (B forms) and have "National
Ambulatory Medical Care Survey 2010 Patient Record Folio" printed at the top.

Item-by-Item Instructions and Definitions for Completing the NAMCS-30 Patient
Record Form

1. PATIENT INFORMATION

ITEM 1a.

DATE OF VISIT

Record the month, day, and 2-digit year of arrival in figures, for example, 05/17/10 for
May 17, 2010.
ITEM 1b.

ZIP CODE

Enter 5-digit ZIP Code from patient’s mailing address.
ITEM 1c.

DATE OF BIRTH

Record the month, day, and 4-digit year of the patient's birth in figures, for example,
06/26/2007 for June 26, 2007. In the rare event the date of birth is unknown, the year of
birth should be estimated as closely as possible.
ITEM 1d.

SEX

Check the appropriate category based on observation or your knowledge of the patient or
from information on the medical record.
ITEM 1e.

ETHNICITY

Ethnicity refers to a person's national or cultural group. The NAMCS Patient Record form
has two categories for ethnicity, Hispanic or Latino and Not Hispanic or Latino.
Mark the appropriate category according to your usual practice, based on your knowledge
of the patient or from information in the medical record. You are not expected to ask the
patient for this information. If the patient's ethnicity is not known and is not obvious,
mark the box which in your judgment is most appropriate. The definitions of the
categories are listed below. Do not determine the patient’s ethnicity from their last name.
Ethnicity

Definition

Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or
Central American or other Spanish culture or origin,
regardless of race.

Not Hispanic or Latino

All other persons.

ITEM 1f.

RACE

Mark all appropriate categories based on observation or your knowledge of the patient or
from information in the medical record. You are not expected to ask the patient for this
information. If the patient's race is not known or not obvious, mark the box(es) which in
your judgment is (are) most appropriate. Do not determine the patient’s race from their
last name.
Race

Definition

White

A person having origins in any of the original peoples of
Europe, the Middle East or North Africa.

Black or African American

A person having origins in any of the black racial
groups of Africa.

Asian

A person having origins in any of the original peoples of
the Far East, Southeast Asia, or the Indian subcontinent
including, for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippine Islands,
Thailand, and Vietnam.

Native Hawaiian or
Other Pacific Islander

A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.

American Indian or Alaska Native

A person having origins in any of the original peoples of
North America, and who maintains cultural
identification through tribal affiliation or community
recognition.

ITEM 1g.

EXPECTED SOURCE(S) OF PAYMENT FOR THIS VISIT

Mark (X) ALL appropriate expected source(s) of payment.

Expected Source(s) of Payment

Definition

Private insurance

Charges paid in-part or in-full by a private insurer (e.g.,
Blue Cross/Blue Shield) either directly to the
physician/CHC provider or reimbursed to the patient.
Include charges covered under a private insurance
sponsored prepaid plan.

Medicare

Charges paid in-part or in-full by a Medicare plan.
Includes payments directly to the physician/CHC
provider as well as payments reimbursed to the patient.
Include charges covered under a Medicare sponsored
prepaid plan.

Medicaid or CHIP/SCHIP

Charges paid in-part or in-full by a Medicaid plan.
Includes payments made directly to the physician/CHC
provider as well as payments reimbursed to the patient.
Include charges covered under a Medicaid sponsored
prepaid plan or the Children’s Health Insurance
Program (CHIP), formerly known as the State
Children’s Health Insurance Program (SCHIP).

Worker’s compensation

Includes programs designed to enable employees injured
on the job to receive financial compensation regardless
of fault.

Self-pay

Charges, to be paid by the patient or patient’s family,
which will not be reimbursed by a third party. "Selfpay" includes visit for which the patient is expected to
be ultimately responsible for most of the bill, even
though the patient never actually pays it. DO NOT
check this box for a copayment or deductible.

No charge/Charity

Visits for which no fee is charged (e.g., charity, special
research or teaching). Do not include visits paid for as
part of a total package (e.g., prepaid plan visits, postoperative visits included in a surgical fee, and
pregnancy visits included in a flat fee charged for the
entire pregnancy). Mark the box or boxes that indicate
how the services were originally paid.

Other

Any other sources of payment not covered by the above
categories, such as CHAMPUS, state and local
governments, private charitable organizations, and other
liability insurance (e.g., automobile collision policy
coverage).

Unknown

The primary source of payment is not known.

ITEM 1h.

TOBACCO USE

Tobacco use is defined as smoking cigarettes/cigars, using snuff, or chewing tobacco.
Mark “Not current” if the patient does not currently use tobacco. Mark “Current” if the
patient uses tobacco. Mark “Unknown” if it cannot be determined whether the patient
currently uses or does not use tobacco.

2. INJURY/POISONING/ADVERSE EFFECT

ITEM 2.

IS THIS VISIT RELATED TO ANY OF THE FOLLOWING?

If ANY PART of this visit was related to an injury or poisoning or adverse effect of
medical or surgical care (e.g., unintentional cut during a surgical procedure, foreign object
left in body during procedure) or an adverse effect of a medicinal drug, then mark the
appropriate box. The injury/poisoning/adverse effect does not need to be recent. It can
include those visits for follow-up of previously treated injuries and visits for flare-ups of
problems due to old injuries. This item not only includes injuries or poisonings, but also
adverse effects of medical treatment or surgical procedures. Include any prescription or
over-the-counter medication involved in an adverse drug event (e.g., allergies, overdose,
medication error, drug interactions).
Injury/Poisoning/
Adverse effect

Definition

1 Unintentional
injury/poisoning

Visit related to an injury or poisoning that was unintentional, such as an
insect bite.

2 Intentional
injury/poisoning

Visit was related to an injury or poisoning that was intentional, such as a
suicide attempt or assault.

3 Injury/poisoning –
unknown intent

Visit related to an injury or poisoning, but the intent is unknown.

4 Adverse effect of
medical/surgical
care or adverse
effect of medicinal
drug

Visit due to adverse reactions to drugs, adverse effects of medical
treatment or surgical procedures.

5 None of the above

Visit not related to an injury, poisoning, or adverse effect of medical or
surgical care or an adverse effect of a medicinal drug.

3. REASON FOR VISIT

ITEM 3.

PATIENT’S COMPLAINT(S), SYMPTOM(S), OR OTHER
REASON(S) FOR THIS VISIT (use patient’s own words)

Enter the patient's complaint(s), symptom(s), or other reason(s) for this visit in the
patient's own words. Space has been allotted for the “most important” and two “other”
complaints, symptoms, and reasons as indicated below.
(1) Most important
(2) Other
(3) Other
The Most Important reason should be entered in (1). Space is available for two other
reasons in (2) and (3). By “most important” we mean the problem or symptom which, in
the physician's/CHC provider’s judgment, was most responsible for the patient making
this visit. Since we are interested only in the patient's most important complaints/
symptoms/reasons, it is not necessary to record more than three.
This is one of the most important items on the Patient Record form. No similar data on
office-based visits are available in any other survey and there is tremendous interest in the
findings. Please take the time to be sure you understand what is wanted--especially the
following three points:

●

We want the patient's principal complaint(s), symptom(s) or other
reason(s) in the patient’s own words. The physician/CHC provider may
recognize right away, or may find out after the examination, that the real
problem is something entirely different. In item 3 we are interested in
how the patient defines the reason for the visit (e.g.,“cramps after eating,”
or “fell and twisted my ankle”).

●

The item refers to the patient’s complaint, symptom, or other reason for
this visit. Conceivably, the patient may be undergoing a course of
treatment for a serious illness, but if his/her principal reason for this visit
is a cut finger or a twisted ankle, then that is the information we want.

●

There will be visits by patients for reasons other than some complaint or
symptom. Examples might be well baby check-up or routine prenatal
care. In such cases, simply record the reason for the visit.

Reminder: If the reason for a patient's visit is to pay a bill, ask the physician to complete
an insurance form, or drop off a specimen, then the patient is not eligible for the sample.
A Patient Record form should not be completed for this patient.

4. CONTINUITY OF CARE

ITEM 4a.

ARE YOU THE PATIENT’S PRIMARY CARE PHYSICIAN/
PROVIDER?

The primary care physician/provider plans and provides the comprehensive primary health
care of the patient. Mark “Yes” if the health care provided to the patient during this visit
was from his/her primary care physician/provider and skip to item 4b. If the provider
seen at this visit was substituting for the primary care physician/provider, also check
“Yes.” Mark “No” if care was not from the primary care physician/provider or
“Unknown” if it is not known.
If “No” or “Unknown” is checked, also indicate whether the patient was referred for
this visit by another health care provider. This item provides an idea of the “flow” of
ambulatory patients from one provider to another. Mark the “Yes,” “No,” or “Unknown”
category, as appropriate.
Notice that this item concerns referrals to the sample physician/CHC provider by a
different physician, provider, or office. The interest is in referrals for this visit and not in
referrals for any prior visit.
Referrals are any visits that are made because of the advice or direction of a
physician/provider other than the physician/provider being visited.
ITEM 4b.

HAS THE PATIENT BEEN SEEN IN YOUR PRACTICE
BEFORE?

“Seen” means “provided care for” at any time in the past. Mark “Yes, established patient”
if the patient was seen before by any provider or staff member in the office/CHC. Exclude
this visit.
Mark “No, new patient” if the patient has not been seen in the office/CHC before.
If “Yes” is checked, also indicate approximately how many past visits the patient has
made to this office/CHC within the last 12 months using the write-in box provided. Do
not include the current visit in your total. If you cannot determine how many past visits
were made, then mark “Unknown.” Include all visits to other physicians/CHC providers
or health care providers in this office/CHC.

ITEM 4c.

MAJOR REASON FOR THIS VISIT

Mark the major reason for the patient’s current visit. Be sure to check only one of the
following “Major Reasons:”
Problem

Definition

New problem (<3 mos. onset)

A visit for a condition, illness, or injury having a
relatively sudden or recent onset (within three months
of this visit).

Chronic problem, routine

A visit primarily to receive care or examination for a
pre-existing chronic condition, illness, or injury (onset
of condition was three months or more before this visit).

Chronic problem,
flare-up

A visit primarily due to sudden exacerbation of a preexisting chronic condition.

Pre-/Post-surgery

A visit scheduled primarily for care required prior to or
following surgery (e.g., pre-surgery tests, removing
sutures).

Preventive care

General medical examinations and routine periodic
examinations. Includes prenatal and postnatal care,
annual physicals, well-child exams, screening, and
insurance examinations.

5. PROVIDER’S DIAGNOSIS FOR THIS VISIT

ITEM 5a.

AS SPECIFICALLY AS POSSIBLE, LIST DIAGNOSES
RELATED TO THIS VISIT INCLUDING CHRONIC
CONDITIONS.

(1) Primary diagnosis
(2) Other
(3) Other
This is one of the most important items on the Patient Record form. Item 5a(1) refers
to the provider’s primary diagnosis for this visit. While the diagnosis may be tentative,
provisional, or definitive it should represent the provider's best judgment at this time,
expressed in acceptable medical terminology including “problem” terms. If the patient
was not seen by a physician, then the diagnosis by the main health care provider should be
recorded (this includes diagnoses made by mid-level providers at CHCs).
17

If a patient appears for postoperative care (follow-up visit after surgery), record the
postoperative diagnosis as well as any other. The postoperative diagnosis should be
indicated with the letters “P.O.”
Space has been allotted for two “other” diagnoses. In Items 5a(2) and 5a(3) list the
diagnosis of other conditions related to this visit. Include chronic conditions (e.g.,
hypertension, depression, etc.), if related to this visit.
ITEM 5b.

REGARDLESS OF THE DIAGNOSES WRITTEN IN 5a, DOES
PATIENT NOW HAVE:

The intent of this item is to supplement the diagnosis reported in item 5a(1), 5a(2), and
5a(3). Mark all of the selected condition(s) regardless of whether it is already reported in
item 5a. Even if the condition is judged to be not clinically significant for this visit, it
should still be checked. General descriptions for each condition are listed below.
Condition

Description

Arthritis

Includes those types of rheumatic diseases in which
there is an inflammation involving joints, (e.g.,
osteoarthritis, rheumatoid arthritis, acute arthritis,
juvenile chronic arthritis, hypertrophic arthritis, Lyme
arthritis, and psoriatic arthritis).

Asthma

Includes extrinsic, intrinsic, and chronic obstructive
asthma.

Cancer

Includes any type of cancer (ca), such as carcinoma,
sarcoma, leukemia, and lymphoma.
Select the appropriate cancer stage based on
information from the medical record by the
treating physician seeing the cancer patient.
Definitions of cancer stages can vary by type of
cancer. See below for examples of cancer stages.

0 In situ
1 Stage I
2 Stage II
3 Stage III
4 Stage IV
5 Unknown stage

In situ
Stage I
Stage II
Stage III
Stage IV
Unknown stage

}

Cerebrovascular disease

Includes stroke and transient ischemic attacks (TIAs).

Chronic renal failure

Includes end-stage renal disease (ESRD) and chronic
kidney failure due to diabetes or hypertension.

Congestive heart failure

Congestive heart failure (CHF).

COPD

Chronic obstructive pulmonary disease. Includes
chronic bronchitis and emphysema. Excludes asthma.

Depression

Includes affective disorders and major depressive
disorders, such as episodes of depressive reaction,
psychogenic depression, and reactive depression.

Diabetes

Includes both diabetes mellitus and diabetes insipidus.

Hyperlipidemia

Includes hyperlipidemia and hypercholesterolemia.

Hypertension

Includes essential (primary or idiopathic) and secondary
hypertension.

Ischemic heart disease

Includes angina pectoris, coronary atherosclerosis, acute
myocardial infarction, and other forms of ischemic heart
disease.

Obesity

Includes body weight 20% over the standard optimum
weight.

Osteoporosis

Reduction in the amount of bone mass, leading to
fractures after minimal trauma.

None of the above

Mark (X) if none of the conditions above exist.

Several cancer staging systems exist. A cancer patient’s prognosis and treatment is
determined using the American Joint Committee on Cancer (AJCC) Cancer Staging
Handbook. For comparability of stage and treatment results over time, the Surveillance,
Epidemiology and End Results (SEER) Summary Stage is still collected and used. Below
is a scheme of how the staging systems compare. The stage should be derived from the
medical record using information from the treating physician (medical oncologist or
surgeon) seeing the cancer patient. This information can usually be found in the last
section of the written or dictated notes from the patient’s visit (usually in the section
labeled Impression and Plan).
Comparability between AJCC staging system and SEER Summary Stage
with the exception of prostate cancer
AJCC
Stage

SEER Summary Stage

In item 5b(3), mark box

0 (In situ)

In situ

0 – In situ

Localized

1 – Stage I

Regional (by direct extension or positive
lymph nodes)

2 – Stage II

III

Regional (by direct extension or positive
lymph nodes)

3 – Stage III

Distant (cancer found in other organs)

4 – Stage IV

Unknown

5 – Unknown stage

NOTE: Whether a cancer is designated as Stage II or Stage III can depend on the specific
type of cancer.
Prostate cancer represents a special situation as most patients do not undergo surgery. The
table below provides a summary of the equivalent correlations between the staging
systems.
Comparability between AJCC staging system and SEER Summary Stage for
prostate cancer
Prostate (AJCC)

Prostate Cancer (SEER)

In item 5b(3), mark
box

0 (In situ)

In situ

0 – In situ

I (T1a) no extension
(Stage A)
II (T2b, T1c, T2) no
extension, negative lymph
nodes (Stage B)
III (T3) negative lymph
nodes (Stage C)

Localized (confined to prostate
gland)

1 – Stage I

Localized (confined to prostate
gland)

2 – Stage II

Regional (extends to other organs,
no lymph nodes involved)

3 – Stage III

IV (T4) positive lymph
nodes (Stage D)
Distant metastases

Regional (extends to other organs;
lymph nodes involved)
Distant metastases

4 – Stage IV

Unknown

5 – Unknown stage

6. VITAL SIGNS

(1) Height

Record the patient’s height if measured at this visit and enter the
value in the box indicating the type of measurement (ft/in or cm).
If it was not measured at this visit and the patient is 21 years of
age or over, then review the chart (up to 1 year) for the last time
that height was recorded and enter that value.

(2) Weight

Record the patient’s weight if measured at this visit and enter the
value in the box indicating the type of measurement (lb or kg). If
it was not measured at this visit and the patient is 21 years of age
20

or over, then review the chart (up to 1 year) for the last time that
weight was recorded and enter that value.
(3) Temperature

Record the patient’s initial temperature if measured at this visit.
Mark the appropriate box, indicating the type of measurement
(degrees C or F).

(4) Blood pressure

Record the patient’s initial blood pressure if measured at this
visit. Enter the systolic and diastolic values in the appropriate
box.

7. DIAGNOSTIC/SCREENING SERVICES

Mark all services that were ordered or provided during this visit for the purpose of
screening (i.e., early detection of health problems in asymptomatic individuals) or
diagnosis (i.e., identification of health problems causing individuals to be symptomatic).
EACH SERVICE ORDERED OR PROVIDED SHOULD BE MARKED. At visits for a
complete physical exam, several tests may be ordered prior to the visit, so that the results
can be reviewed during the visit. Since these services are related to the visit, the
appropriate box(es) should be marked.
Mark the “NONE” box, if no examinations, imaging, blood tests, scope procedures, or
other tests were ordered or provided.
Services meriting special attention are as follows:
Answer
Box

Service

Special Instruction

Foot exam

Includes visual inspection, sensory exam, and pulse
exam.

Retinal exam

Includes ophthalmoscopy, funduscopic exam, and
dilated retinal exam (DRE).

Lipids/
Cholesterol

Include any of the following tests - cholesterol, LDL,
HDL, cholesterol/HDL ratio, triglycerides, coronary risk
profile, lipid profile.

Scope Procedure – Specify

Mark (X) for scope procedures ordered or provided.
Write in the type of procedure in the space provided.

Biopsy-Specify

Include any form of open or closed biopsy of lesions or
tissues. Specify the site of the biopsy.

Answer
Box

Service

Special Instruction

Chlamydia test

Only include the following tests if chlamydia is
specifically mentioned: enzyme-linked immunosorbent
assay (ELISA, EIA), direct fluorescent antibody test
(DFA), nucleic acid amplification test (NAAT), nucleic
acid hybridization test (DNA probe testing), or
chlamydia culture.

HPV/DNA test

Detects the presence in women of human
papillomavirus and is performed by collecting cells
from the cervix.

Pap Test - conventional

Refers to a smear spread on a glass slide and fixed.

Pap Test – liquid-based

Refers to a specimen suspended in liquid solution.

Other exam/test/service –
Specify

Mark (X) for services ordered and provided that are not
listed. Write in the service(s) in the space provided.

8. HEALTH EDUCATION

Mark all appropriate boxes for any of the following types of health education ordered or
provided to the patient during the visit. Exclude medications.

Health Education
NONE

Definition
No health education was provided.

Asthma education

Information regarding the elimination of allergens that
may exacerbate asthma, or other activities that could
lead to an asthma attack or instruction on the use of
medication, such as an inhaler.

Diet/Nutrition

Any topic related to the foods and/or beverages
consumed by the patient. Examples include general
dietary guidelines for health promotion and disease
prevention, dietary restrictions to treat or control a
specific medical problem or condition, and dietary
instructions related to medications. Includes referrals to
other health professionals, for example, dietitians and
nutritionists.
22

Exercise

Any topics related to the patient's physical conditioning
or fitness. Examples include information aimed at
general health promotion and disease prevention and
information given to treat or control a specific medical
condition. Includes referrals to other health and fitness
professionals. Does not include referrals for physical
therapy. Physical therapy ordered or provided at the
visit is listed as a separate check box in item 9.

Family planning/Contraception

Information given to the patient to assist in conception
or intended to help the patient understand how to
prevent conception.

Growth/Development

Any topics related to human growth and development.

Injury prevention

Any topic aimed at minimizing the chances of injury in
one’s daily life. May include issues as diverse as
drinking and driving, seat belt use, child safety,
avoidance of injury during various physical activities,
and use of smoke detectors.

Stress management

Information intended to help patients reduce stress
through exercise, biofeedback, yoga, etc. Includes
referrals to other health professionals for the purpose of
coping with stress.

Tobacco use/exposure

Information given to the patient on issues related to
tobacco use in any form, including cigarettes, cigars,
snuff, and chewing tobacco, and on the exposure to
tobacco in the form of "secondhand smoke." Includes
information on smoking cessation as well as prevention
of tobacco use. Includes referrals to other health
professionals for smoking cessation programs.

Weight reduction

Information given to the patient to assist in the goal of
weight reduction. Includes referrals to other health
professionals for the purpose of weight reduction.

Other

Check if there were other types of health education
ordered or provided that were not listed above.

9. NON-MEDICATION TREATMENT

Mark (X) all non-medication treatments ordered or provided at this visit.
Non-Medication Treatment
NONE

Definition
No non-medication treatments were ordered, scheduled,
or performed at this visit.

Complementary alternative medicine
(CAM)

Includes medical interventions neither widely taught in
medical schools nor generally available in physician
offices or hospitals (e.g., acupuncture, chiropractic,
homeopathy, massage, or herbal therapies).

Durable medical equipment

Equipment which can withstand repeated use (i.e.,
could normally be rented and used by successive
patients); is primarily used to serve a medical purpose;
generally is not useful to a person in the absence of
illness or injury; and is appropriate for use in the
patient’s home (e.g., cane, crutch, walker, wheelchair).

Home health care

Includes services provided to individuals and families in
their places of residence for the purpose of promoting,
maintaining, or restoring health or for maximizing the
level of independence while minimizing the effects of
disability and illness (including terminal illness).
Services may include skilled nursing care; help with
bathing, using the toilet, or dressing provided by home
health aides; and physical therapy, speech language
pathology services, and occupational therapy.

Physical therapy

Physical therapy includes treatments using heat, light,
sound, or physical pressure or movement (e.g.,
ultrasonic, ultraviolet, infrared, whirlpool, diathermy,
cold, or manipulative therapy).

Speech/Occupational therapy

Speech therapy includes the treatment of defects and
disorders of the voice and of spoken and written
communication. Occupational therapy includes the
therapeutic use of work, self-care, and play activities to
increase independent function, enhance development,
and prevent disability.

Psychotherapy

All treatments involving the intentional use of verbal
techniques to explore or alter the patient’s emotional
life in order to effect symptom reduction or behavior
change.

Other mental health counseling

General advice and counseling about mental health
issues and education about mental disorders. Includes
referrals to other mental health professionals for mental
health counseling.

Excision of tissue

Includes any excision of tissue. Excludes wound care
and biopsy.

Wound care

Includes cleaning, debridement, and dressing of burns;
repair of lacerations with skin tape or sutures. Include
removal of foreign bodies only if a wound exists. If an
object is removed from an orifice, mark (X) the “Other
non-surgical procedures” box and specify the
procedure.

Cast

Application of a rigid dressing made of plaster or
fiberglass molded to the body while pliable and
hardening as it dries, to give firm support.

Splint or wrap

Application of a rigid or flexible appliance used to
maintain in position a displaced or moveable part, or to
keep in place and protect an injured part. May also be
made of plaster, but is not circumferential.

Other non-surgical procedures-Specify

Write-in any non-surgical procedure ordered or
performed at this visit that was not previously recorded.

Other surgical procedures-Specify

Write-in any surgical procedure ordered or performed at
this visit that was not previously recorded. Surgical
procedures may be simple (e.g., insertion of intrauterine
contraceptive device) or complex (e.g., cataract
extraction, hernia repair, hip replacement, etc.).

10. MEDICATIONS & IMMUNIZATIONS

If medications or immunizations were ordered, supplied, administered, or continued at this
visit, list up to 8 in the space provided using either the brand or generic names. Record
the exact drug name (brand or generic) written on any prescription or on the medical
record. Do not enter broad drug classes, such as “laxative,” “cough preparation,”
“analgesic,” “antacid,” “birth control pill,” or “antibiotic.” The one exception is “allergy
shot.” If no medication was prescribed, provided, or continued, then mark the “NONE”
box and continue.
Medication, broadly defined, includes the specific name of any:

●

Prescription and over-the-counter medications, anesthetics, hormones,
vitamins, immunizations, allergy shots, and dietary supplements

●

Medications and immunizations which the physician/CHC provider
ordered or provided prior to this visit and instructs or expects the patient
to continue taking regardless of whether a “refill” is provided at the time
of visit

For each medication, record if it was new or continued.
If more than eight drugs are listed, then record according to the following level of
priority:
1.
2.
3.
4.

All medications (including OTC drugs)/immunizations associated with
the listed diagnoses
All new medications (including OTC drugs)/immunizations, excluding
vitamins and dietary supplements
All continued medications (including OTC drugs)/immunizations,
excluding vitamins and dietary supplements
Vitamins and dietary supplements

11. PROVIDERS

Mark all providers seen during this visit. If care was provided, at least in part, by a person
not represented in the five categories, mark the “Other” box.
For mental health provider, include psychologists, counselors, social workers, and
therapists who provide mental health counseling. Exclude psychiatrists.

12. VISIT DISPOSITION

Mark all that apply.
Visit Disposition

Definition

Refer to other physician

The patient was instructed to consult or seek
care from another physician/provider. The
patient may or may not return to this
office/CHC at a later date.

Return at specified time

The patient was told to schedule an
appointment or was given an appointment to
return to the office/CHC at a particular time.
26

Visit Disposition

Definition

Refer to ER/Admit to
hospital

The patient was instructed to go to the
emergency room/department for further
evaluation and care immediately or the patient
was admitted as an inpatient in the hospital.

Other

Any other disposition not included in the above
list.

13. TIME SPENT WITH PROVIDER

Include here the length of time the physician/CHC provider spent with the patient. DO
NOT include the time the patient spent waiting to see the physician/CHC provider or
receiving care from someone other than the physician/CHC provider. For example, DO
NOT include the time someone other than the sampled provider spent giving the patient an
inoculation or the time a technician spent administering an electrocardiogram. It is
entirely possible that for visits such as these, the patient would not see the physician/CHC
provider at all. In that case, “0” minutes should be recorded. DO NOT include
physician’s/CHC provider’s time spent preparing for a patient such as reviewing the
patient’s medical records or test results before seeing the patient.
If more than one patient is seen by the physician/CHC provider at the same time,
apply the following rule:
If the physician/CHC provider can easily separate the time spent with each (e.g., 3 minutes
with one and 27 minutes with the other), he/she should record that on the Patient Record
forms. If the physician/CHC provider cannot easily estimate how much time was spent
with each, he/she should divide the total time equally among the patients seen together.

14. LABORATORY TEST RESULTS

If you received a NAMCS-30A, please disregard this section; however, if you were
given a NAMCS-30B, this item instruction applies to you. Please pay particular
attention to these instructions.
The biggest NAMCS change for 2010 is the addition of an A & B PRF folio. The A folio
contains the same questions as 2009; however, the B folio, the one which you received,
has additional items that capture laboratory values associated with cardiovascular risk
factors. The American Heart Association recently released a scientific statement that
recommended collecting lipoproteins, blood glucose, and glycohemoglobin to track the
progress in meeting national goals for heart disease and stroke prevention and
management. The American Heart Association specified in its guidelines that adding
27

these data elements to the NAMCS would represent a low-cost approach to enhance
national surveillance for cardiovascular disease.
Because your primary specialty indicated that you are likely to perform certain
cardiovascular tests, you were been selected to receive the NAMCS 30B. The new lab
questions (item 14) appear on the back of the PRF and include space to enter if six
laboratory tests were drawn, the most recent result, and the date the lab was drawn. Please
remember that the values should be from the current visit or values obtained within the
past 12 months from the sampled visit. If any of these tests were ordered at the current or
recent visit, but are not included in the medical record, do not follow-up and obtain the
information at a later date.

EXHIBIT A
NAMCS-30A PATIENT RECORD FORM

E-1

NAMCS-30B PATIENT RECORD FORM

E-2

E-3

EXHIBIT B
NAMCS PARTICIPANT WEB PAGE

E-4

EXHIBIT C
PATIENT VISIT WORKSHEET - EXAMPLE WITH SAMPLING PATTERN *
Start With (SW) with the 2nd patient. Take Every (TE) 5th patient listed on the log during the rest of the
reporting period.

Patient Visit Worksheet
Physician's/Provider’s Name: Marcus Welby, M.D.
Place An
"X" For The
Selected
Patient
Visits

Patient's Name

Mario McCool
X

Suzi Rudai
Maria Wuming Shi
Juan Conte
Margarita Naamalum
Ivan Poe

Jean Alguien
Alicia De Tal
Isabel Suieto
Ana Voe
Laura Bleau

Tito Hablador
Pepe Citizen
Pierre Naturaleza
Carlos Del Pueblo
Pedro Habitante

Wakenya Zoe
Rafael Individuo
Carmen Nom

E-5

Jan Koe
Ram Roe
X

Roberto Nombre

* All Names and examples referenced in this instruction booklet are fictional and in no
way represent actual situations or individuals

E-6

EXHIBIT D
Patient Visit Worksheet
Physician's/Provider’s Name:
Place An
"X" For
The Selected
Patient
Visits

Patient's Name

E-7